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BACKGROUND

Marsha Linehan was bom on May 5,1943. She is an American psychologist and author, and her primary work has been with suicidal clients, clients with substance abuse problems, and clients with BPD. When Linehan began her work as a psychologist in the 1970s, she sought to develop a successful treatment for individuals who were actively suicidal (Van Nuys, 2007). During an interview about DBT, she stated,

My real target and focus was the person who found life so painful and the anguish so insurmountable that they truly wanted to be dead. I went to work with this group of people and I thought that I could treat them with the existing, of-the-day cognitive behavior therapy. . .. I was out not only to save the world but quite confident I could do it. (Van Nuys, 2007)

Linehan (1993a) created DBT after her clinical work indicated that her persistently suicidal clients had a high incidence of being raised in invalidating environments, resulting in demands for a therapeutic environment of unconditional acceptance. Her work with clients exposed to these invalidating environments during upbringing or due to biological factors, who react abnormally to emotional stimulation, revealed patterns of behavior including levels of excitement going up much more quickly, peaking at a higher intensity, and taking more time to return to baseline. This explained why individuals with BPD demonstrate catastrophe-driven lives and rapid emotional shifts. Because of their past invalidation, clients do not have any methods for coping with these sudden, powerful surges of emotion. Linehan explained that her clients came in, and . . . these people had so many problems. They were such an ever changing set of problems, so that one day it was one thing and another day, another. If you worked on one problem, another problem was more intolerable. You try to work on that problem and the person says, "well, I'm going to kill myself, this is all hopeless." (Van Nuys, 2007)

As a result, Linehan recognized that successful treatment was related to clients' willingness to change. This willingness to change appeared to be affected by people's ability to cope with stressors and accept their level of emotional dysfunction. Linehan discovered a significant deficiency in standard cognitive and behavioral treatments, which focused almost entirely on helping clients modify their thoughts, feelings, and behaviors. A treatment solely focused on change tended to be unacceptable to these clients, who often felt invalidated and criticized and dropped out of treatment. Obviously, if clients do not attend treatment, they cannot benefit from treatment. Conversely, a treatment focused entirely on acceptance nullified the seriousness of the client's suffering and the urgent need to produce change. As a result, Linehan (1993a) built DBT around a philosophy that encourages the balance and fusion of both acceptance and change. Acceptance-based interventions, frequently referred to as validation strategies, communicate to the clients that they are both acceptable as they are and that their behaviors, including those that are self-harming, make sense in some way. According to Linehan, [W]ithin every unwise act, there is some inherent wisdom. [Like] taking heroin, which is a long term, dysfunctional, destructive behavior in our culture. Within there, is the wisdom of, "you feel better immediately." So there is dysfunction and function always coexisting together. (Van Nuys, 2007)

Counselors learn to highlight for clients when their thoughts, feelings, and behaviors are "normal," helping clients discover they have sound judgment and are capable of learning how and when to trust themselves. The new emphasis on acceptance does not occur to the exclusion of change. Clients must also change if they want to create a life worth living. The focus on acceptance used in combination with change-based strategies enhances the use of one another. In the course of merging acceptance with change, Linehan noticed that a third set of strategies, dialectics, came into play. Dialectical strategies gave the counselor a means to balance acceptance and change when emotions run high, as they often do in the treatment of clients diagnosed with BPD. Dialectical strategies and a dialectical worldview with an emphasis on wholeness and synthesis enable the counselor to blend acceptance and change in a manner that results in progress, momentum, and flow in individual sessions and across the entire treatment intervention. This counters the tendency, found in treatment of clients diagnosed with BPD, to become hindered by arguments and polarizing or extreme positions. These three sets of strategies together with the theories on which they are based come together to form the foundation of DBT.

Although the use of DBT has expanded to treat populations other than BPD and has been adapted to treat a variety of ages and settings, all treatment approaches are highly structured and all are based on Linehan's original works. Thus, not only did she create this treatment approach, but her work is threaded through every adaptation of this model.

 
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